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HomeMy WebLinkAboutMiscellaneous - 178 GRANVILLE LANE 4/30/2018N w , Location /99 ��� ► �N� ( /v - No. 3OG Date HORTN TOWN OF NORTH ANDOVER i OL Certificate of Occupancy $ uBuilding/Frame Permit Fee $ sa u Foundation Permit Fee $ f Other Permit Fee $ TOTAL $ Check # q t9(S- 4 16u53 / ( 6tx� Building Inspector APPLICATION TO CONSTRUCT BUILDING PERMIT NUMBER: SIGNATURE: TOWN OF NORTH ANDOVER BUILDING DEPARTMENT RENOVATE- OR DEMOLISH A ONE OR TWO 3 ©1!�' ( DATE ISSUED: l^an Z2 of Buildings Date SECTION 1- SITE INFORMATION I 7 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number %� �Q14✓//� N ,r',,--' /�/ / / 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: 3 1&0 Lot Area Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide red Provided RNtured Provided ALI 1.7 WaterSupply M.G.LC.40. 34) 1.3. Public Private ❑ Zone Flood Zone Information: outside Flood Zone 0 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record 0 Nam (Print) Address for Service Signature Telephone 2.2 vm --i- wrd: ()7-1402/6O 46A!5V7` Name P ' Address for Service: SECTION 3 - CONSTRUCTION SERVICES I 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: C.SA V �. Address r. A6tl Signatur Telephone 3.2 Registered Home Improvement Contractoi Company Name Not Applicable ❑ ©EGI 9 z License Number ►-u-0 Expiration Date Not Applicable ❑ /0 / (?(— �, Registration Number 76 - �� � � Expiration Date ■ 0 a a s /a e C R C OT r r r ..9 b7 SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......0 No ....... 0 SECTION 5 Description of Proposed Work check au applicable) New Construction ❑ Existing Building 11 Repair(s) ❑ Alterations(s) ❑ Addition fir Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: 1111ek7k IU7� ov G40X al -c HeUs-0 �e�s�rzrir-� �5 c c �°D rF p,D�G /,qA/I/ D,v ageK of, Nocjs6" ,ac5Gi-1, / A&k /O X iv ow of -AJous'F SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by applicant a �" 1. Building qz (a) Building Permit Fee Multiplier 2 Electrical t J'6Do oo 7 '7 (b) Estimated Total Cost of Construction 3 PlumbingFtp Building Permit fee (a) x (b) 4 Mechanical AC �° . 5 Fire Protection � 6 Total 1+2+3+4+5 (n Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OW RS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, VJ C C. -A s as Owner/Authorized Agent of subject property Hereby thorize/G° /J/� (� L �Dl� / [1 to act on be 1 in all ers elative tow k authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, /YZZZd15 8-,4,LZ1/Qar"x as Owner uthorized Agent f subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief 11_6G� Pr`nt � { �f � Si ature of Own /A en Date NO. OF STORIES SIZV IX 17 /o? x 00 x BASEMENT OR SLAB 19VdJ/0 Lel 1260< SIZE OF FLOOR TRvIBERS / INI2 ND 3RD SPAN DIN ENSIGNS OF SILLS 2.-1)(6 27- DRAENSIONS OF POSTS -- DIMENSIONS OF GIRDERS — HEIGHT OF FOUNDATION ( r> -Y — THICKNESS 0 '/ SIZE OF FOOTING /0 �eo2 O " X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND _5'OLJ0 IS BUILDING CONNECTED TO NATURAL GAS LINE itr0 .. FORM U -LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS SECTION*********************** % APPLICANT.__/&1 /,%('L PHONE >� OZ? LOCATION: Assessor's Map Number PARC EL -7 SUBDIVISION LOT (S) STREET L/� U l (.(— ZJU ST. NUMBER 6 ************************************OFFICIAL USE ONLY*********************************** I RECOMMENDATIONS -OF TOWN AGENTS: I JCONSERVATION ADM ,TOR DATE APPROVED DATE REJECTED COMMENTS W? ava -1153 — TrG-C0n,54r1A��,' Ne4i' dela/_ TOWN PLANNER COMME FOOD INSPECTOR -HEALTH / T SEPTIC INSPECTOR -HEALTH COMMENTS ��Al S 4leA DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTO Revised 9\97 Jim rm ti TE COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION Metropolitan Boston — Northeast Regional Office t JANE SWIFT Governor DEP File # 242-1153 BOB DURAND Secretary LAUREN A. LISS Commissioner RE: NOTIFICATION OF WETLANDS PROTECTION ACT FILE NUMBER NORTH ANDOVER DATE: 7/15/2002 4:26 PM (city/town) The Department of Environmental Protection has received a Notice of Intent filed in accordance with the Wetlands Protection Act (M.G.L. c. 131, §40): Applicant: JOSEPHNALERIE CINERULI Owner: Address: 178 GRANVILLE LANE Address: N.. ANDOVER MA, 01845 - LOCUS: 178 GRANVILLE LANE IF CHECKED, THE FOLLOWING ITEMS) APPLY TO THIS NOTICE OF INTENT: A._(_JThis project has been assigned the following file # : 242-1153 Although a file # is being issued, please note the following: ISSUANCE OF A FILE NUMBER INDICATES ONLY COMPLETENESS OF SUBMITTAL,NOT APPROVAL OF APPLICATION B.( )No file # will be assigned to this project until the following missing information is sent to this office, to meet the minimum -submittal requirements in accordance with the Wetlands Protection Regulations at 3 t J 1.,1JiIl 1 ii.UU: --copy(s) of a completed Notice of Intent (Form 3 or Form 4 of Sect. 10.99, whichever is applicable) and a copy of the Fee Transmittal Form, with a copy of the check for the State's share of the Notice of Intent filing fee 2. ( ) _copy(s) of plans, calculations, and other documentation necessary to completely describe the proposed work and mitigation measures to protect resource areas. 3. ( ) _ copy(s) of an 8.5" X 11" section of the USGS map of the area. 4.( ) cop (s) of plans showing compliance with Title 5 of the State Environmental Code, 310 CMR 15.00. 5. ( ) Proof that a copy of your Notice of Intent has been mailed or hand delivered to the Natural Heritage and Endangered Species Program. COMMENTS: (seepage 2 for additional information) This information is available in alternate format by calling our ADA Coordinator at (617) 574-6872. 205A Lowell St Wilmington, MA 01887 • Phone (978) 661-7600 • Fax (978) 661-7615 • TTD# (978) 661-7679 Co Printed on Recycled Paper 1�tte Corrirr=weaTtS eW .rsaCfi=- to �Departrnetry r.indusi�ialq.� C TGE �lTtUr°S�IDSTS 600 WaS&ngt= Street ' orken' Campcnsation Insurance Amdavit APPLICANT LT`MORMATION Please PRINT Legibiv i Namii1 ?0 A21 e:/.1 IACatiOn: ,G IV �%�/� Telephone "• C� 7` 7�� D I= a homeowner periomung an work myseu D i am sole proprietor and have no one wor=ng in my capacity E'1 am an employer providing workers' compensation for my employees worldng on this job Company Narn:e�:1 Address: lJ �< L�Pi, i C� �✓ City - �(/ �1/Li Telepiwae � �• • insurance Company: Ja � T /7Ur!%/t%L L-15, G Policy : AUIC 700 MM%2 00 D I am (circle one) sole propriemr, general contractor or homeowner and have hired the contractors listed below who have the following, woricers' compensation policies: Company Name: Address: Ciry: Telephone r: inm'ance Company. Company Name: Address: City: Policy r: Telephone Ok insurance Com -Pan -v-.__ Policy": Attach additio=d sheet if necessary Failureto secur5 coverage as required under Seraan 35A of MGL 15B can lead to the imposition of criminal penalties of a line up to n i,50 U.00 and/or one years' imprisonment as well as civil penalties in the ions of a STOP WDP.IL ORDER and a line of OD.O. a day against m-. I understand that .a copy of this statement may be iorwarded to the Office of investigations of the DIA for coverage verification. is true and correct I do hereby certt y uunder ih ins n ties of perjury that the information above 5i�atvse./�`/.l Date -, QPhone a y' 7? Crucial D s e OI,U.,Y - Do not write in this area o Buildino Denartm ent Permit/License f: a Licensing Board city or i ovrn: 0 Selectmen's Dfiiee D Health Deoartmeni D Check if immediate response is required o Other h1assachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law" an employee is defined as every person in- service -of another under any contract of hire, express or implied, oral or written. An employer is defined as an individual, partnership, association, corporation or other lestal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the leLal representatives of a deceased employer, or the receiver or trustee of aninaividual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the -dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section -2 5 also -states that every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the coninionwe alth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally, neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with -the insurance requirements of this chapter have beenpres.ented io.the contracting authority. .. plicants Please isl.l in the workers' compensation affidavit completely, by checking the.box that applies to your situation and supplying company names, address and phone numbeis as all affidavits may be submitted to the. Department of Industrial„ Accidents for.connnation of insurance coverage. Also- be sure to sign and.date the affidavit— The affidavit should.be returned to the city -or town that the application 'TOT the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the "law” -or it you are required to.obTain a workers' compensanonpolicy, please call'the Department at the number listed below. 02�y or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of luvesugations has to contact you. regarding the applicant..Pleas-I.b5 sure to fill in the permit1licens. number which wiL1 be used as a reference number. The affidavits may be returned to the Department by mail or F A_, unless other arrangements have been made. The Office of investigations would like.to thank you inadvance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 W ashinog ton Street. Boston, IY1A 02111 Fax =` (617) 7277-7749 Telephone _ (617) 727-1900 ext. 406, 409, or 375 North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: V/ (Location of Facility) Signature of Permit Applicant 10�a,T0--,>-, Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector MECcheck Compliance Report Massachusetts Energy Code MECcheck Software Version 3.3 Release lc Data filename: Untitled TITLE: cinseruli CITY: North Andover STATE: Massachusetts HDD: 6322 CONSTRUCTION TYPE: l or 2 Family, Detached HEATING SYSTEM TYPE: Other (Non -Electric Resistance) DATE: 10/23/02 DATE OF PLANS: 10/22/2002 PROJECT INFORMATION: cinseruli COMPANY INFORMATION: classic const. co. NOTES: kitchen addition COMPLIANCE: Passes Maximum UA = 36 Your Home = 35 2.8% Better Than Code Permit Number Checked By/Date Gross Glazing Area or Cavity Cont. or Door Perimeter R -Value R -Value U -Factor UA Ceiling 1: Flat Ceiling or Scissor Truss 119 0.0 38.0 3 Wall : Wood Frame, 16" o.c. 226 0.0 13.0 19 Windodv �. Wood Frame, Double Pane with Low -E 10 0.340 3 Door 5: blass 20 0.340 7 Fl" I: All -Wood Joist/Truss, Over Unconditioned Space 119 0.0 30.0 3 COMPLIANCE STATEMENT: The proposed building design described here is consistent with the building plans, specifications, and other calculations submitted with the permit application. The proposed building has been designed to meet the Massachusetts Energy Code requirements in MECcheck Version 3.3 Release 1 c and to comply with the mandatory requirements listed in the MECcheck Inspection Checklist. The heating load for this building, and the cooling load if appropriate, has been determined using the applicable Standard Design Conditions found in the Code. The HVAC equipment selected to heat or cool the building shall MECcheck Inspection Checklist Massachusetts Energy Code MECcheck Software Version 3.3 Release 1 c DATE: 10/23/02 TITLE: cinseruli Bldg. Dept. Use I Ceilings: [ ] I 1. Ceiling 1: Flat Ceiling or Scissor Truss, R-38.0 continuous insulation I Comments: Above -Grade Walls: [ ] 1. Wall]: Wood Frame, 16" o.c., R-13.0 continuous insulation Comments: Windows: 1. Window 2: Wood Frame, Double Pane with Low -E, U -factor: 0.340 For windows without labeled U -factors, describe features: # Panes Frame Type Thermal Break? [ ] Yes [ ] No Comments: Doors: [ ] I 1. Door 5: Glass, U -factor: 0.340 4 Panes Frame Type Thermal Break? [ ] Yes [ ] No Comments: Floors: [ ] I 1. Floor 1: All -Wood Joist/Truss, Over Unconditioned Space, R-30.0 continuous insulation Comments: I Air Leakage: [ ] I Joints, penetrations, and all other such openings in the building envelope that are sources of air leakage must be sealed. [ ] I When installed in the building envelope, recessed lighting fixtures shall meet one of the following requirements: 1. Type IC rated, manufactured with no penetrations between the inside of the recessed fixture and ceiling cavity and sealed or gasketed to prevent air leakage into the unconditioned space. 2. Type IC rated, in accordance with Standard ASTM E 283, with no more than 2.0 cfin (0.944 L/s) air movement from the the conditioned space to the ceiling cavity. The lighting fixture shall have been tested at 75 PA or 1.57 lbs/ft2 pressure difference and shall be labeled. I Vapor Retarder: [ ] I Required on the warm -in -winter side of all non -vented framed ceilings, walls, and floors. Materials Identification: [ ] I Materials and equipment must be identified so that compliance can be determined. [ ] I Manufacturer manuals for all installed heating and cooling equipment and service water heating equipment must be provided. [ ] I Insulation R -values and glazing U -factors must be clearly marked on the building plans or specifications. Duct Insulation: [ ] Ducts shall be insulated per Table J4.4.7.1. Duct Construction: [ ] All accessible joints, seams, and connections of supply and return ductwork located outside conditioned space, including stud bays or joist cavities/spaces used to transport air, shall be sealed using mastic and fibrous backing tape installed according to the manufacturer's installation instructions. Mesh tape may be omitted where gaps are less than 1/8 inch. Duct tape is not permitted. [ ] The HVAC system must provide a means for balancing air and water systems. Temperature Controls: [ ] Thermostats are required for each separate HVAC system. A manual or automatic means to partially restrict or shut off the heating and/or cooling input to each zone or floor shall be provided. Heating and Cooling Equipment Sizing: [ ] Rated output capacity of the heating/cooling system is not greater than 125% of the design load as specified in Sections 780CMR 1310 and J4.4. Circulating Hot Water Systems: [ ] Insulate circulating hot water pipes to the levels in Table 1. Swimming Pools: [ ] All heated swimming pools must have an on/off heater switch and require a cover unless over 20% of the heating energy is from non-depletable sources. Pool pumps require a time clock. Heating and Cooling Piping Insulation: [ ] HVAC piping conveying fluids above 120 OF or chilled fluids below 55 °F must be insulated to the I levels in Table 2. Table 1: Minimum Insulation Thickness for Circulating Hot Water Pipes. Table 2: Minimum Insulation Thickness for HVAC Pipes. Fluid Temp. Insulation Thickness in Inches by Pipe Sizes Piping System Types Range F 2" Runouts l" and Less 1.25' to 2" 2.5" to 4" Heating Systems Low Pressure/Temperature 201-250 Insulation Thickness in Inches by Pipe Sizes Heated Water Non -Circulating Runouts Circulating Mains and Runouts Temperature ( F) Up to 1„ Up to 1.25" 1.5" to 2.0" Over 2" 170-180 0.5 1.0 1.5 2.0 140-160 0.5 0.5 1.0 1.5 100-130 0.5 0.5 0.5 1.0 Table 2: Minimum Insulation Thickness for HVAC Pipes. Fluid Temp. Insulation Thickness in Inches by Pipe Sizes Piping System Types Range F 2" Runouts l" and Less 1.25' to 2" 2.5" to 4" Heating Systems Low Pressure/Temperature 201-250 1.0 1.5 1.5 2.0 Low Temperature 120-200 0.5 1.0 1.0 1.5 Steam Condensate (for feed water) Any 1.0 1.0 1.5 2.0 Cooling Systems Chilled Water, Refrigerant, 40-55 0.5 0.5 0.75 1.0 and Brine Below 40 1.0 1.0 1.5 1.5 NOTES TO FIELD (Building Department Use Only) be no greater than 125% of the design load as specified in Sections 780CMR 1310 and J4.4. Builder/Designer Date Beam B3, Lo ridge TJ-BeamTM v5.55^ Serial 'Nber:7001 4 2 Pcs of 1.75" x 9.25" 1.9E Microllam4 LVL BEAMUSA 1111 2/6/200 1:17:48 PM , Page 1 of 1 Build Code: 146 THIS PRODUC TS OR EXCEEDS THE SET DESIGN CONTROLS FOR THE APPLICATION AND LOADS LISTED n ;n e -12'3 15116" Product Diagram is Conceptual. LOADS: Analysis for Beam Member Supporting FLOOR - RES. Application. Tributary Load Width: 7' 3" Loads(psf): 40 Live at 100% duration; 13 Dead; 0 Partition SUPPORTS: INPUT BEARING REACTIONS(lbs.) WIDTH LENGTH LIVE/DEAD/TOT. PLY DEPTH DETAIL OTHER 1 2x4 Plate 3.50" 2.25" 1788 / 636 / 2424 1 9.2" Detail A3 1.25" LSL Rim 2 2x4 Plate 3.50" 2.25" 1788 / 636 / 2424 1 9.2" Detail A3 1.25" LSL Rim - See TJ SPECIFIER'S / BUILDER'S GUIDES for detail(s): A3. DESIGN CONTROLS: - Deflection Criteria: STANDARD(LL: U360, TL:U240). - Bracing(Lu): All compression edges (top and bottom) must be braced at 2'8" o/c unless detailed otherwise. Proper attachment and positioning of lateral bracing is required to achieve member stability. ADDITIONAL NOTES: - IMPORTANT! The analysis presented is output from software developed by Trus Joist (TJ). TJ warrants the sizing of its products by this software will be accomplished in accordance with TJ product design criteria and code accepted design values. The specific product application, input design loads, and stated dimensions have been provided by the software user. This output has not been reviewed by a TJ Associate. - Not all products are readily available. Check with your supplier or TJ technical representative for product availability. - THIS ANALYSIS FOR TRUS JOIST PRODUCTS ONLY! PRODUCT SUBSTITUTION VOIDS THIS ANALYSIS. - Allowable Stress Design methodology was used for Code BOCA analyzing the TJ Residential product listed above. - Note: See TJ SPECIFIER'S / BUILDER'S GUIDES for multiple ply connection. PROJECT INFORMATION MAXIMUM DESIGN CONTROL CONTROL LOCATION Shear(lb) 2358 2006 6151 Passed(33%) Lt. end Span 1 under Floor loading Moment(ft-lb) 7071 7071 11204 Passed(63%) MID Span 1 under Floor loading Live Defl.(in) 0.327 0.400 Passed(U440) MID Span 1 under Floor loading Total Defl.(in) 0.444 0.600 Passed(U324) MID Span 1 under Floor loading - Deflection Criteria: STANDARD(LL: U360, TL:U240). - Bracing(Lu): All compression edges (top and bottom) must be braced at 2'8" o/c unless detailed otherwise. Proper attachment and positioning of lateral bracing is required to achieve member stability. ADDITIONAL NOTES: - IMPORTANT! The analysis presented is output from software developed by Trus Joist (TJ). TJ warrants the sizing of its products by this software will be accomplished in accordance with TJ product design criteria and code accepted design values. The specific product application, input design loads, and stated dimensions have been provided by the software user. This output has not been reviewed by a TJ Associate. - Not all products are readily available. Check with your supplier or TJ technical representative for product availability. - THIS ANALYSIS FOR TRUS JOIST PRODUCTS ONLY! PRODUCT SUBSTITUTION VOIDS THIS ANALYSIS. - Allowable Stress Design methodology was used for Code BOCA analyzing the TJ Residential product listed above. - Note: See TJ SPECIFIER'S / BUILDER'S GUIDES for multiple ply connection. PROJECT INFORMATION OPERATOR INFORMA Colonial Drafting Gelinas Structural Enc Cinseruli Residence Dan L. Gelinas 178 Granville Lane 579ANorth End BjgdO Norht Andover, MA 01845 isbu MA G f952 Phone 978-465-6436 Fax (Same) Copyright ® 2000 by Trus Joist, a Weyerhaeuser Business. TJ-ProTM and TJ -Beam'*' are trademarks of Trus Joist. Microllam®is a registered trademark of Trus Joist. ■ BOISE' BC CALCO 2002 DESIGN REPORT - US Wednesday, October 23, 2002 12:57 File Double 13/4" x 18" VERSA -LAM@ 2900 SP Name - CINSERULI : FB02 Job Name - CINSERULI Description - Address - 178 GRANDVILLE LANE Specifier - City, State, Zip - NORTH ANDOVER, MA Designer - North Reading I.S. Customer - Company - Moynihan Lumber Code reports - ICBO 5512, BOCA 98-52, SBCCI 9852 Misc - 2ND FLOOR BEAM BO��JBI 7604 lbs LL i"/`?M P © P6 1111d 6p_ 7604 lbs LL 4168 lbs DL 4168 lbs DL General Data ID Version: US Imperial Member Type: - Floor Beam Number of Spans - 1 Left Cantilever - No Right Cantilever - No Slope 0/12 Tributary 06-00-00 Repetitive n/a Construction Type n/a Live Load Dead Load Part Load Duration 30 PSF 10 PSF 0 PSF 100 Disclosure The completeness and accuracy of the input must be verified by anyone who would rely on the output as evidence of suitability for a particular application. The output above is based upon building code -accepted design properties and analysis methods. Installation of BOISE engineered wood products must be in accordance with the current Installation Guide and the applicable building codes. To obtain an Installation Guide or if you have any questions, please call (800)232-0788 before beginning product installation. BC CALC@, BC FRAMER®, BCI®, BC RIM BOARD-, BC OSB RIM BOARD-, BOISE GLULAMT"" VERSA -LAM@, VERSA -RIM@, VERSA -RIM PLUS@, VERSA-STRANDTm, VERSA -STUD@, ALLJOIST@ and AJS'rm are registered trademarks of Boise Cascade Corporation. Page 1 of 1 Total Horizontal Length - 16-08-00 Load Summary ID Description S Standard 1 CJ SHED ROOM 2 SHED ROOF 3 MAIN HSE ATTIC LO 4 MAIN ROOF LOAD 5 OUTSIDE WALL LOAD Controls Summary Control Type Value Load Type Ref. Start End Live Dead Trib. Dur. Unf.Area Load Left 00-00-00 16-08-00 30 PSF 10 PSF 06-00-00 100 Unf.Area Load Left 00-00-00 16-08-00 10 PSF 10 PSF 03-06-00 100 Unf.Area Load Left 00-00-00 16-08-00 35 PSF 15 PSF 03-06-00 115 Unf.Area Load Left 00-00-00 16-08-00 20 PSF 10 PSF 06-00-00 100 Unf.Area Load Left 00-00-00 16-08-00 35 PSF 15 PSF 13-00-00 115 Unf.Lin. Load Left 00-00-00 16-08-00 0 PLF 80 PLF n/a 115 Moment 49053 ft -lbs End Shear 9654 lbs Total Deflection U277 (0.721") Live Deflection U429 (0.466") Max. Defl. 0.721" (Limit: 1") Span/Depth 11.1 %Allowable Duration 97.7% @ 115% 68.9% @ 115% 86.5% 83.8% 72.1% Loadcase Span Location 3 1 - Internal 3 1 -Left 3 1 3 1 3 1 1 NOTES: Design meets Code minimum (L/240) Total load deflection criteria. Design meets Code minimum (L/360) Live load deflection criteria. Design meets arbitrary (1") Maximum load deflection criteria. Minimum bearing length for BO is 4". Minimum bearing length for B1 is 4". Entered/Displayed Horizontal Span Length(s) = Clear Span + 1/2 min. end bearing + 1/2 intermediate bearing C/) 13 U) CO 0 CA 10 � , z CD O wa, wwr,, ^W W r �to O Odc v CL Q CO CD O .. 0 d lmO CC CD CO) d O CO) 'O �• C C y n CD O rl• CD CD3 CO) co CA O CCD 0 CD 3 o - 0 G cc O H O O h1 � �, O � �• CT W CDCL 'V O a- `- n Cl, 0 CD Cl CJS r X rD Cl) O p OTJ OH C9 C3. n Z =r -fl H �_ mo CL 0 m m a ?dy CD H CD ...� O p o i= _ O = o .. o +:j r) m o Z t. 0 y 0 0 CD :� m r^ V) _06 C* CD y • CD • CD CD CD O e -r . ,►/,L1, lu O fir d N ' CS :•� �`�+ V J O� W •� d H CD .x�y C/) %vto CA m f • O o o : 4 Z C�: L CD GOs 00 a S A �-• cn m o CD Z: • O =M: n r• CCU,CD o = 3 o - 0 G 7 O h1 � �, O � r' n o 'V O a- `- n a- O a W. CJS r X rD Cl) O p OTJ y 0 0 c TOWN OF NORTH ANDOVER BUILDING DEPARTMENT 'LI�ATIO(N TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: � DATE ISSUED: SIGNATURE: Building CommiSSionerfl for of Buildings Date ' SECTION I- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: / 7 P -/(?" v11, 17 l it/ 7 _I d � C. , n (2,e 11 vf) /r=ex AIA Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Z l I .0 3 AU15s I S07 Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS (ft) Front Yard Side Yard Rear Yard Required Provide Required Provided Re red Provided H � 10 1.7 Water Supply UG.LC.40.34) I.S. Flood Zone Information: Public Private 0 Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal 0 On Site Disposal System if SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT z. i owner of rcecoro )C (-.m Signature Telephone 78 Address for Service 7? -6n-0 / 2.2C1we--eat d: _1L/_c�-� Name P ' Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 L.kensed Construction Supervisor: Licensed Construction Supervisor: S� L �i�'14&0621/e kl1q, Address Sig/natit-ra Telephone 3.2 Registered Home Improvement Contractor y Name Address i Sign-Sture ' r ! T Not Applicable ❑ O O/9 _ License Number 1-14-03 Expiration Date Not Applicable ❑ 10 7?3,5— Registration Number �- r7- o L� Expiration Date 1 0 a a a s C 2 rr aas C r IT ra r SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 Workers Compensation Insurance affidavit must be completed and subs in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... 0 SECTION 5 Description of Proposed Work check all appUcable New Construction ❑ 1 Existing Building Q I Repair(s) 25c(6) A with this railure to provide this athdavit will result ❑ 1 Alterations(s) ❑ I Addition 9 - Accessory Bldg. ❑ I Demolition ❑ 1 Other ❑ Specify I Brief Description of Proposed Work. ®��s72v`% A0,01i/Ung �4r���c ///K7 0,V,3/06< �.O�rJS �l�rC.7 ��w'c� �b✓'Clf �,('G�G l,��i / y� C/ /t.� l.3AC'K' Ur= M���S� 17r50'G A ACOS ICA ow 4c.4C 0'e - SECTION F SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit appliiant 1. Building (a) Building Permit Fee Multi lier 2 Electrical a 4 (b) estimated Total Cost of Construction 3 Plumbin r© Building Permit fee (,) x (b) 4 Mechanical HVAC o� 5 Fire Protectiono 6 Total 1+2+3+4+5 (a -V 41 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNnRS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT Hereby as Owner/Authorized Agent of subject property -"to act on in all ers elative to work authorized by this building permit application. Sm ature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, �������� J� ���1��G1� as Owner uthorized Agent f subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief of Date NO. OF STORIES SIZ 7X 17 !o? x 77, BASEMENT OR SLAB />V/ / PCra pKa� SIZE OF FLOOR TIMBERS / IST2 3 SPAN RD DIMENSIONS OF SILLS - X DRvfENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS r � SIZE OF FOOTING /U �(a p " X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND SaLA) IS BUILDING CONNECTED TO NATURAL GAS LINE Al -,o Location No. Date .. 0 M TOWN OF NORTH ANDOVER n Certificate of Occupancy $ Building/Frame Permit Fee $ j5 <� Foundation Permit Fee $ - Other Permit Fee $ l Sewer Connection. Fee $ WaN Connection Fee � $ TOTAL��� Building Inspector Div. Public Works Location I LNCa Date "ORT" 'of TOWN OF NORTH ANDOVER 9 Certificate of Occupancy $ } Building/Frame Permit Fee $ Mus t� Foundation Permit Fee $ Other Permit Fee $ Sewer`Eon eccion Fee $ Water Connection Fee $ TOUL11 $ i"5 .:� `'' Building Inspector Div. Public Works 0 z M O z N F N N w W m E C 0 0 J LL LL 0 W N N N ' IJ I A LL 0 N z 0 N z Z W < i N o LL. 4t O__ Q Z u F D. 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Z 0 1 < W 1 W I J D \ _U m O Z l) 1 N < K F J C LwW - W J a N IL W t � Cpl V Om �OpNi-mpO1 b y yO = 1 Znnn w0,�0 Da �On� 0a Op D J 00 D INGz0 yO c3�-D< w m 0 DN T Tn7C 7Cnn v NnxZu n nmy ) py; rm{3O C.v OC) OOOOONONN OO � c O myT�c OD < zzZZZOOvaNmPm n O O" 3 Nm O wo ZT N > a- m N 9. r) D O OZ x p p 3 0 mDD�s °O yI�Z, N0 O ZN w 3 = AD Z Z3 m 0� m DO mN O Z L 1 10 iI I FF z z Dp v m rTO y�zx IM Gm _v� D D a N O aDO t0 3TTm OzZ _Z c0 z a: aO Z ODN X O NNF n xy y 3N n v na vx , 0 p CT nC Z Z p^ mp �v rl (NO x DyZ Z OO N OZ y Z v Dv Dyn 0 O� OZ A X m7~o 00 O am zz Z p Z Z p D m p p m Z Z N X G1 O O m p I I IIIIIL,Li Ll IIII!ill IIIIIIIW IIIA 0 0 c b D Z A SON N N -'m z MN� • DO NZZ Cv3 C ITI �X-N{ 3>o Ox 0�0 uu v pmx - IzD _INn Nip i �Z- mN3 fT" O Z DmN m�0 NCN 0r 00 -1 or goo Zgz . �z =v v N m> 10 mm N -n y Town of North Andover BUILDING DEPARTMENT Homeowner License Exemption (Please print) DATE ,Ta LV / 7 JOB LOCATION 179 Number Street Address E S'. t—::- Section of town "HOMEOWNER" 4L1 � cTC f�Pll,Li /t ��7 c� 4617-017'_2-6 000 Name Home Phone Work Phone PRESENT MAILING ADDRESS 176 1e-AK/V!z_4_E y9iuE- iUC)i2 c� _ A rtJbc� U�l� M Z9 746-1V s City/Town State Zip code The current exemption for "homeowners" was extended to include owner occupied.dwellings of six units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. (State Building Code, Section 109.1.1) DEFINITION OF HOMEOWNER: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one to six family dwell- ing, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, on a form acceptable to the Bulding Official, that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other applicable codes, by-laws, rules and , regulations. The undersigned "homeowner" certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNER'S SIGNATURE YA Vase,, APPROVAL OF BUILDING OFFIQ�AL Note: Three family dwellings 35,000 cubic feet, or larger, will be required to comply with State Building Code Section 127.0, Construction Control. V A f\ V0a 0 it LTJ n 00 e a NOW z 'm ( , m z '-1 CO) 3 o m o -- ao c m m 31 o m n=r ,1 °—' CO) m �. m o m m n T1!0 01(a o c (Dc m o v O T m z n > Z Z N Z A n p p CA F) O _ = O • 0 c OD C� � 1��� � � b � Dg(* N I 5/4 xi S E cn ops -1--D F-Vri �-s 2 CC @►rTS Fon- ,5v? por4 PA -D 36 vv ti i tl ti I � FI-Nl�ti�� r_j Ob x No.: W S NOV 2 3 1988 Date 1I - 23- 7)9, /N OF NORTH ANDOVER BUILDING DEPARTMENT N/Frame Permit Fee Jation Permit Fee Permit Fee \ $ `O Buildi g ln`speitok V zl < L N N W Z Y U_ I F W l7 Q F Z 0 K 4 f 0 J 4 0 W K Y W Z I O I Z U tL O O 4 <J 4 0 N_ W N i 3 W z 0 z O J 7 m N r-� 41 l r F u a z < J 0 z F C 6 u E W a 0 O O z z z 1 m u W W a 0 in K P., 2 a z 0 K P o < J uW ] 0 L a W Z K Z W t7 U1 ZK 0 J 4 O F m < i 0 W 0 m F O N N F i > 01 z 0 0 Vl 0 4 Z L I O U < ! < z 2 m Z K 0 O f IFA ] < 0 u u O f Wj N w W W 4 z a s a u 3 �+ O W ] n W K m F O 0 O r < Z t7 a J J z N O W K W J t7 f iz C U Z p - N m W W C < W W < < 0 J J N L L W < L O YI IL L m u W W a 0 in K P., 2 000 m W 1fl WW u Z QIr No _a �I aha 0 aJ. J07 - ILz0 0 N Z=N omuQ NLLJ w0a INw Z SON uu►I Qz� W1W 3oN U f'X� NWW 7IL �Z(A ZQU1 UN!- WW W N J W N (7 N 10< W W O O�0 c�z_ Z Q oOfLLa� Z— w z z Z: LL ,=„, D00Z Z 00 < p Ou Y 0 O p m]] U U 3 Q<> M M �I IFI Z Z O � IIT I17-F U W 1 1 <W� p rol Z W f O Z � x 0< 0 Z 0 U 0 w oW< z �w W� a LL LL - 0, 0u 3�sz u< Q OLL D 00onu N m O <Q N NII Q^ Y Z Y- 1I�1TlalD— z 0 0 u 0 Q i Z Y Z W W aaz O m0 m W � � Ili M N F Q W W O O�0 c�z_ Z Q oOfLLa� Z— w z z Z: LL ,=„, D00Z Z 00 < p Ou Y 0 O p m]] U U 3 Q<> M M �I IFI Z Z O � IIT I17-F U W 1 1 <W� LL U U � < Y Z f O Z � x 0< 0 U 0 w o Z E": a LL LL i 0, 0u w m u< W W O O�0 c�z_ Z Q oOfLLa� Z— w z z Z: LL ,=„, D00Z Z 00 < p Ou Y 0 O p m]] U U 3 Q<> M M O O .FI b Z SID Z X W a LL I f z 2 3 x 0< 0 U 0 N m O Z O Z:E w N m O <Q N Q^ Y Z Y- O O .FI b WOOD STOVE INSTALLATION CHECKLIS�,PM14IT No: �s�a I � Permit A building permit is required for the installation of any solid fuel burning appliance. The building permit and installation inspection are limited to the stove installation and not to the stove construction. Stove A. New Used B. Type/radiant _Circulating C. Manufacturer A40') T C,vs Lk) t' _Lab. No. 1-1A+JdAA 4 iNSz Name/Model No. VI 1-0,AL,,;1_ Collar size S Xis Ut)n L 1-" i 7 " "A v4 (Dimensions/ Height -3y Length 2 Width Chimney A. New Existing B. Size (flue area) 14UNLe C. Other appliances attached to flue (Number and flue size) 00 D. Prefab (Manufacturef—narpe andtye E. Masonry/LinedXQd �' Flue liner UA type 3 manufacturer) Unlined S e F. Height (refer to diagrams) C i � ls'' LN'�3- cap ®v�1 L t� ty 0,004 P t; w s' i o cle. OVER lo' -}2 WK 3' xIN ;o _ CHIMNEY HEIGHT Hearth (non-combustible) A. Materials ti B. Sub -floor construction C. Minimum dimensions (refer to diagram tp. QA' 1 t Clearances and Wail Protection (see stove install tion ciear� ses chart) A. Type of wall protection provided ,L{ c)t- . J B. Clearances (refer to diagrams) c-Q¢*49,n4e • l� r wt l3L. [JIAcoc-r.( FIREPLACE CORNER HEARTH WALUCENTER 13 rA a 12" �Mi1N. `�1i 7 f (FUEL/i�SH .ALGE5y51C1� HEARTH WALUCENTER 13 r 1" Figure 2109.4 factory -built chimney roof support support bracket connector pipe non-combustible wall protection connector overlap woodburning stove non-combustible floor protection Figure 2109.4 STOVE INSTALLATION CLEARANCES 12 1. Front: Fuel or ash access side. 2. Non-combustible spacers required. 3. Clearances on each side of a radiant stove with a heat shield shall be measured as if a circulating type. Note: Clearances shall be measured perpendicular to stove body. Laboratory verified test clearances permitted. 4. Thimble required for passage through combustible construction. .A Combustible '.,z " Asbestos Millboaro Concretes Masonry Spaced Out 1 " Stove Components Material Spaced Out 1 ' 2. Foundation Wall 4" Brick Veneer Radiant Stove( 1.5 -Front 36" — — - Circulating Stove(1. -Front 24" — — - A. RadiantStove(3) —Sider BackiTop 36 18" 6" 18" A. Circulating Stove —side,, Back/Too 12 6" 6.. 6^ B. Single Wall '(i/) Connector Pipe 18•• 12" 6" 8„ B. Insulated Connector Pipe 2 2" 2" 2" C. Chimney Height (Metal or Masonry) Three (3) feet above adjacent roof and two (2) feet above any roof ridge within 10 feet D. Damper If a damper is not included in the stove construction, it must be installed.in the connector pipe. 12 1. Front: Fuel or ash access side. 2. Non-combustible spacers required. 3. Clearances on each side of a radiant stove with a heat shield shall be measured as if a circulating type. Note: Clearances shall be measured perpendicular to stove body. Laboratory verified test clearances permitted. 4. Thimble required for passage through combustible construction. .A 3 0 FE4 I � ct Vi • 3 z cn Z V) „ O Z� U� z U a.r � Vi LL LLJ Lr) CL C:) w U a F— cam!) u.J Lu z 00 0- ZD 0 00 •C O d r w 0 z O a r.a 3-� N .Q � cc oc An _ O 0 � a L a r C 0 s C oc . Q V c a. W W O 0 oc W a Z a •C a Q w C H Z m V z to W W W C W Z 0 to — h J LAJC Z u _Z Q v o m m U L C J L J L •` L Y j E c0 j (C W j i0 j N O o f C o c o o E Q U ii OC ii ¢ CO U. Q ii m to FE4 I � ct Vi • 3 z cn Z V) „ O Z� U� z U a.r � Vi LL LLJ Lr) CL C:) w U a F— cam!) u.J Lu z 00 0- ZD 0 00 •C O d r w 0 z O a r.a 3-� N Q Z .Q An a E a L a C s C a. Ecg c a. 0 oc ao Z = •C a Q w C m V In to W C m CL to J Q Z A U y z A y � W .c •� y o> O a °� U) y it z � a �0 O ° O W= C14o w A y z y O oo r ii E '� p z' p a t� cc A ° $I L u �� H Date ..�.... ��....�..'c-3........ TOWN OF NORTH ANDOVER PERMIT FOR WIRING i This certifies that ....:.r.:....... ..., ....... �°`...� .^ —. ...........,........................................................ has permission to perform :.....:. rt"� ............................................................. wiring in the building,of ... �r ...........................,............................................ i at ..... /7-Z .....: ' .. "`X '� `: �—� �� `'" ....... North Andover, Mass. Fee. ............... Lic. N . 3�= ...v ...................................................... ELECTRICAL INSPECTOR Check # y< d 9 4 4 i 3 �-N, THE09MM0NWE4L2H0FAt14n40RSE77S Office Use only DEPARTA&W0FPUB1ICS4FM Permit No. y4// t3 BOARD OFMEPREYEM7ONPEGULANOAND70MR12:QD — � i Occupancy &Fees Checked PPLICATTONFOR PERMIT TO PERFORM ELECTRICAL WO ALL WORK TO BE PERFORMED IN ACCORDANCE wiTH THE MASSACHUSSTS EI.EemcAL CODE, 527 CMR 12:00 ^ Z (PLEASE PRINT IN INK OR TYPE ALL IN Dat E Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street J Owner or Tenant Owner's Address Is this permit in conjunction with a building permit: Yes No (Check Appropriate Box) Purpose of Building L Utility Authorization No. Existing Service Amps^ V oits Overhead [D Underground No. of Meters New Service Amps / Volts Overhead ED Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work OP, K1TCNAvV,5vA14&R-V--tooqz— n No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA ao ground ri _ground No., of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets ` No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges / Y ^, No. of Air Cond. Total 2 3 I V 7 V Tons No. of Detection and No. of Disposals No. of Heat Total Total Pumps Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers 7 Space Area Heating KW I No. of Self Contained Detection/Sounding Devices Local Municipal Other No. of Dryers Heating Devices KW Connections �. No. of Water Heaters KW No. of No. of Signs Bailasis No. Xydro Massage Tubs No. of Motors Total HP OTHER h7strartoe PutsttantfothetegtmarteiisofMa�td>t�sGet>Ba1L�vs IhmaomerrtLiabkhuaa=poirynixhwca cmaag£crdsabgmtdapvalatt YES EJ NO Iha%esthmffidwhdprcdaf=neJoft0 m YES = No IfjwbmedmdwdYES,plea9enk*thetypecfcovagebycllad�tg>Ete IlsBURANCE BOND UMER 0' (PkmeSpecity) 69JV9PAL $IG DW akbStalt Ll �%3 E�atedVahx&3eclri WWak $. W hVeclicnDa�Rewftd Roo HnW FsilgR�MI /qA I v �� j__503 n LioatseNa , . J, Li Ism �/ 1 Sigrrl Li =,"To A -i-: � I �/ t5� t/ d� 4WU&6,�5 ✓1 r (� AftT&No. OWNER'SiNRRANCEWAM3Z-,IamawmdxtdxL msedmW iiniraneWatt a> Ie asmgtmadby smGenaal (Laws antl�mysigts�taeonths penttitatwai� this tegtmarte{tt (Please check one) Owner Agent6 Telephone No. PERMIT FEE `� Name The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Please Print Name: Location: City Phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. Comnanv name: Address r City: Phone # Insurance. Co. PollcV # Company name: Address City: Phone # insurance Co. Policy # Failure to secure coverage as required. under Section 25A or MGL 152 can lead to the imposition of criminal penalties cf.a fine up to 31,500.00 and/or one years' impnsorrnent-as-welLas-mMimOaltiesJn-iheicm-&A 3DP.Vl DW -OR Agi-wd_afio -ctA$I 1D.M-asiay.-kgainstmp- I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. / do hereby certdy under the pains and penalties of perjury that the information providb°d above is true and correct. Signature Date Print name P.bone.# Official use only do not write in this area to be completed by city or town officiar City or Town P Building Dept []Cheek if immediate response is required 0 Licensure Board Selectman's Office Contact person: Phone #: E] Health Department Other a NORTH O 9 "SA MUS Date.. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ...... ............ has permission to perform ... /�'n'-� ..`.................. . plumbing in the buildings of .( .................... . 7) �... ..' .! ......'........ , North Andover, Mass. at............ Fee. Lie. No.). I: ! ..... ....... . PLUMBING INSPECTOR Check # ? _" 1 } l 2—, 5564 r V MASSACHUSETTS UNIFORM AP (NnttorType) PLICATION FOR PERMIT TO DO PLUMBING Mass. ®ate 3 _r— P it C^ �C � ems # y Building Location Owner's Name_ M F, t^3nSF: ` 1- I 'V .-i Type of Occupancy e5 New ❑ Renovation L Replacement ❑ Plans Submitted: Yes ❑ No ri FIXTURES Installing Company NameA c r+ W � C41l C Pjul T,41 Address Q3 '13 D ck _r4-, Wobyry) III at of TO Business Telephone 0 9'33 - Name of Licensed Plumber Check one: ❑ Corporation ❑ Partnership Pe hrm/Co. Cert)f)cate INSURANCE COVERAGE: I have acurr yesliability Insuran11 ce policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. No If you have c ked yes, please Indicate the type coverage by checking the appropriate box. A liability Insurance policy 0 Other type of Indemnity ❑ Bond ❑ OWNER'S INSURANCE: WAIVER: I am aware that the licensee does not have theinsurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ Signature of Owner or Owner's Agent 1 hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Cie 9 L_C Title signature of UcensedPlumber City/Town Type of License: Master []Journeyman OFFICE USE ON — License Number oh! S h- to H 0 O Z4C cc O W 0 h a! W N Z W F- x V 3 X y Z Q O m a a K W )P.< ¢ g< tW.. N W Z -, C a A. < m O z < cc a < e: � v. X a O '� x x W J O S d J H h• Z < O .1 A N 4 z Z Lt W OG �W, < O O V < S h Y m N G ° S 1-10 is a O sub—BSMT. BASEMENT IST FLOOR LL 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR S H FLOOR 7TH FLOOR t STH FLOOR Installing Company NameA c r+ W � C41l C Pjul T,41 Address Q3 '13 D ck _r4-, Wobyry) III at of TO Business Telephone 0 9'33 - Name of Licensed Plumber Check one: ❑ Corporation ❑ Partnership Pe hrm/Co. Cert)f)cate INSURANCE COVERAGE: I have acurr yesliability Insuran11 ce policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. No If you have c ked yes, please Indicate the type coverage by checking the appropriate box. A liability Insurance policy 0 Other type of Indemnity ❑ Bond ❑ OWNER'S INSURANCE: WAIVER: I am aware that the licensee does not have theinsurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ Signature of Owner or Owner's Agent 1 hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Cie 9 L_C Title signature of UcensedPlumber City/Town Type of License: Master []Journeyman OFFICE USE ON — License Number oh! S